Review Question - QID 218780

This patient presenting with poorly controlled episodic hypertension, palpitations, and diaphoresis has a rare adrenal tumor called pheochromocytoma, which can be cured through surgery. This patient requires guidance in making a clearly superior treatment choice that is curative, which is the goal of directive counseling.

Directive counseling refers to a process through which a provider informs, explains, interprets, and advises the patient towards making a treatment choice that is clearly superior. The goal of directive counseling is to replace decision-making that is driven by emotion with decision-making driven by logical thought processes. Directive counseling places the provider in a supportive role to guide the patient towards a rational decision without exerting authoritarian control. Importantly, the provider is not directing the patient towards a paternalistic decision but rather helping the patient make logical decisions. This method is effective for encouraging patients to make treatment choices in cases where certain treatments are clearly superior and patients are reacting out of emotion rather than rational behavior.

Mills and Haga studied the role of personalized medicine in genomic counseling with the advent of next-generation testing. The authors found that there has been a tradition of non-directive methods used in genetic counseling. They recommended that directive counseling may be required in cases of genetic counseling where behavioral modification clearly leads to better outcomes.

Incorrect Answers:
Answer 1: Assisted decision-making refers to a process through family members may assist a patient in making a decision but not make the decision themselves. Ultimate decision-making authority would still reside with the patient. For example, a family member of a patient with dementia who is considering elective surgery may help that patient weigh the risks and benefits of surgery. It is most helpful when patients who have mental or cognitive impairments are deciding between treatment choices that are not clearly better than one another and have inherent tradeoffs. In this case, one treatment choice is clearly superior.

Answer 3: Informed refusal is the negative corollary of informed consent. Patients can give informed refusal if they have medical decision-making capacity because patient autonomy should be respected. However, before accepting a patient's refusal of a clearly superior treatment, directive counseling should be performed so that the risks and benefits of treatment can be intellectualized and rationalized, especially if the patient is reacting out of emotion.

Answer 4: Shared decision-making is used when there is clinical equipoise between 2 or more treatment options. In shared decision-making, the physician and patient discuss the patient's preferences and values in the context of different treatment choices to arrive at a decision that is both medically feasible and consistent with the patient's preferences. In contrast, there is no clinical equipoise in this case.

Answer 5: Substituted judgement should be used when the patient lacks decision-making capacity and there is no advance directive. In those cases, the order of surrogate decision-makers is spouse, adult child, parent, and adult sibling. Substituted judgement is not appropriate in this case because there is no evidence that this patient lacks capacity.

Bullet Summary:
Directive counseling should be used to guide patients when there is a treatment choice that is clearly superior.